VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE
4916 West Norfolk Road
Portsmouth, VA 23703
(757) 483-1780

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 5, 2022 and Dec. 6, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

ISP documentation to identify type of assistive devices needed for the resident.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 12/05/22 from 8:38 a.m. to 4:35 p.m. and 12/06/22 from 8:45 a.m. to 4:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and activities were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The record of resident #5 includes an assessment of serious cognitive impairment dated 11/23/22 which includes a response of ?No? for the question ?is the individual unable to recognize danger or protect his/her own safety and welfare.? 2. The record of resident #5 includes an approval for placement in special care unit dated 11/22/22. 3. Staff #6 and staff #7 acknowledged the assessment of serious cognitive impairment dated 11/23/22 in the record for resident #5 included a response for ?No? for the question ?is the individual unable to recognize danger or protect his/her own safety and welfare.?
Plan of Correction:	What Has Been Done to Correct? The assessment of serious cognitive impairment was sent to the physician to be updated. How Will Recurrence Be Prevented? The Resident Care Director or designee will review the assessment of serious cognitive impairment and ensure that it is filled out correctly by the physician prior to admission. All resident charts will be reviewed for accuracy. Person Responsible: Resident Care Director or designee
Standard #:	22VAC40-73-410-A
Description:	Based on the onsite record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record of resident # 1 did not include documentation of an orientation upon his admission date of 03/25/22. 2. Staff #6 and staff #7 acknowledged documentation on an orientation was not included in the record for resident #1.
Plan of Correction:	What Has Been Done to Correct? The resident acknowledged that he had received orientation on day of admission. The acknowledgement was place in his record. How Will Recurrence Be Prevented? The administrator will follow the audit guide for each new resident to ensure that every resident has documentation of having received orientation. Person Responsible: Administrator or designee
Standard #:	22VAC40-73-450-C
Description:	Based on record review the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs based upon the uniform assessment instrument (UAI). Evidence: 1.The record of resident # 6 UAI dated 09/26/22 documented a mechanical and human help need for transferring. The need for mechanical and human help for transferring was not included on the ISP dated 11/01/22. 2. Staff # 6 acknowledged the ISP in the record for resident #6 dated 11/01/22 did not include the need for transferring as identified on the UAI dated 09/26/22.
Plan of Correction:	What Has Been Done to Correct? The ISP record for resident #6 was reviewed and updated accordingly to reflect current need. How Will Recurrence Be Prevented? The RCD will review the resident records to ensure that the ISP reflects the needs identified on the UAI as updates occur. All resident charts will be reviewed for accuracy. Person Responsible: Resident Care Director or designee
Standard #:	22VAC40-73-560-E
Description:	Based on record review the facility failed to ensure all resident records shall be kept current and retained at the facility. Evidence: 1. The record of resident #1 includes an ISP dated 6/13/22 which identifies ?DNR: CPR will be withheld in the event of cardiac/respiratory arrest per Durable Do Not Resuscitate.? The record did not include a DNR order. 2. Resident #1 record included a personal and social data information which documents a response of ?n/a? for the section ?information on advance directives, DNR orders or organ donation if applicable.? 3. Staff # 6 and staff #7 acknowledged a copy of the DNR order was not in the record for resident # 1.
Plan of Correction:	What Has Been Done to Correct? The ISP record for resident #1 was changed to reflect current DNR status. How Will Recurrence Be Prevented? The RCD will review the resident records to ensure that the ISP reflects current code status. All resident charts will be reviewed for accuracy. Person Responsible: Resident Care Director or designee
Standard #:	22VAC40-73-860-G
Description:	Based on observation the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. During the onsite inspection, the water temperature in room # 130 was measured 127 degrees F. The water temperature in Room # 131 was measured to 129 degrees F. 2. Staff # 10 acknowledged the water temperatures in Room 130 and Room 131 to exceed the required degrees.
Plan of Correction:	What Has Been Done to Correct? The maintenance director adjusted the water heater immediately to get the desired temperature. How Will Recurrence Be Prevented? The maintenance director will continue to do weekly water temperature checks in random resident rooms and will continue to document them in the designated binder. The maintenance director will place mixing valves on the water source for units 130 and 131 to ensure that the water is able to stay at the desired temperature. Person Responsible: Maintenance Director or designee